Provider Demographics
NPI:1538242482
Name:JACK, MICHAEL ALAN (DDS ,MS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:JACK
Suffix:
Gender:M
Credentials:DDS ,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 FIXLER DRIVE
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281
Mailing Address - Country:US
Mailing Address - Phone:330-334-1967
Mailing Address - Fax:
Practice Address - Street 1:822 PORTAGE TRAIL
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221
Practice Address - Country:US
Practice Address - Phone:330-929-2853
Practice Address - Fax:330-929-3821
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH173571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics